Fill and Sign the Notice Dishonored Form

SECOND NOTICE OF DISHONORED CHECK Date: ___________________________ To:                               On ________________ , 20 ___ , we informed you that we received a check, number ___________ , payable to [business/individual] ___________________________ , c ontaining your name and address in the sum of $ ___________ , drawn upon [bank or institution] ___________________________ , account # ________________ . We have received no information that this was a stolen check. The bank has indicated that the check has been dishonored by the bank for the following reasons: ___________________________ ___________________________ ___________________________ We notified you that you were responsible for the face value of the check ($ ___________ ) plus the fees authorized under G.S. 25-3-506 ($ ___________ ) and G.S. 6-21.3(a) ($ ___________ ) for a total amount due of $ ___________ . Thirty days have passed since the mailing of that notification letter, and you have not made payment to us for that total amount due. Under G.S. 6-21.3, we claim you are now liable for the face value of the check, the fees, and treble damages. The damages we claim are three times the amount of the check or one hundred dollars ($100.00), whichever is greater, but cannot exceed five hundred dollars ($500.00). The total amount we claim now due is: Face value of the check $ ___________ Processing fee authorized under G.S. 25-3-506 $ ___________ Bank service fees authorized under G.S. 6-21.3 $ ___________ Three times the face value of the check, with a minimum of $100.00 and a maximum of $500.00 $ ___________ Total amount due: $ ___________ - 1 - Payment of the total amount claimed above within 30 days of the mailing of this letter shall satisfy this civil remedy for the returned check. If payment has not been received within this 30-day period, we will seek appropriate relief before a court of proper jurisdiction for full payment of the check plus all costs, treble damages, and witness fees. If you do not believe you are liable for these amounts, you will have a right to present your defense in court. To pay the check or obtain information, contact the undersigned at the above business location. Cash or a bank official check will be the only acceptable means of redeeming the dishonored check. If you do not believe that you owe the amount claimed in this letter or if you believe you have received this letter in error, please notify the undersigned at the above business location as soon as possible. Make your payment payable to ________________________________ at the following address: Mail or deliver the total amount to the following:                               Notice Issued by: Signature: ________________________________ Print Name: _______________________ Title: _______________________ - 2 -